Coping Strategies for Health and Daily-Life Stressors in Patients With Rheumatoid Arthritis, Ankylosing Spondylitis, and Gout STROBE-Compliant Article Ingris Pela´ez-Ballestas, PhD, Annelis Boonen, PhD, Janitzia Va´zquez-Mellado, PhD, Isabel Reyes-Lagunes, PhD, Adolfo Herna´ndez-Gardun˜o, PhD, Maria Victoria Goycochea, MSc, Ana G. Bernard-Medina, MD, Jacqueline Rodrı´guez-Amado, MD, Julio Casasola-Vargas, MD, Mario A. Garza-Elizondo, PhD, Francisco J. Aceves, MSc, Clara Shumski, MD, Ruben Burgos-Vargas, MD, on behalf of REUMAIMPACT group
Abstract: This article aims to identify the strategies for coping with health and daily-life stressors of Mexican patients with chronic rheumatic disease. We analyzed the baseline data of a cohort of patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout. Their strategies for coping were identified with a validated questionnaire. Comparisons between health and daily-life stressors and between the 3 clinical conditions were made. With regression analyses, we determined the contribution of individual, socioeconomic, educational, and health-related quality-of-life variables to health status and coping strategy. We identified several predominant coping strategies in response to daily-life and health stressors in 261 patients with RA, 226 with AS, and 206 with gout. Evasive and reappraisal strategies were predominant when patients cope with health stressors; emotional/negative and evasive strategies predominated when coping with daily-life stressors. There was a significant association between the evasive pattern and Editor: Robert L. Barkin. Received: January 29, 2015; revised: February 5, 2015; accepted: February 6, 2015. From the Department of Rheumatology (IP-B, JV-M, JC-V, RB-V), Hospital General de Me´xico ‘‘Eduardo Liceaga,’’ Mexico City, Mexico; Maastricht University Medical Center (AB), The Netherlands; Postgraduate Department of Psychology (I-RL), Universidad Nacional Auto´noma de Me´xico, Mexico City; Department of Pediatrics (A-HG), Hospital Universitario ‘‘Jose´ Eleuterio Gonzalez’’, Monterrey, Nuevo Leon; Clinical Epidemiology Unit (MVG), Hospital Gabriel Mancera Regional 1, IMSS, Mexico City; Department of Rheumatology (AGB-M), Hospital Civil de Guadalajara, Guadalajara, Jalisco; Department of Rheumatology (JR-A, MAG-E), Hospital Universitario ‘‘Jose´ Eleuterio Gonzalez,’’ Monterrey, Nuevo Leon; Hospital General de zona 46 (FJA), IMSS and Unidad de Investigacio´n Croˆnico-Degenerativas, Guadalajara, Jalisco; and Department of Rheumatology (CS), Hospital Central, PEMEX, Mexico City, Mexico. Correspondence: Prof. Rube´n Burgos-Vargas, Department of Rheumatology, Hospital General de Me´xico and Faculty of Medicine, Universidad Nacional Auto´noma de Me´xico, Dr Balmis 148, colonia Doctores, Me´xico DF 06720, Me´xico (e-mail: [email protected]). IP-B and RB-V equally contributed to this study. This work was supported by the funds provided by the Salud 2002-C01-6434 programs of the National Council of Science and Technology of Me´xico (CONACYT). The authors have no conflicts of interest to disclose. Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000000600
Medicine
Volume 94, Number 10, March 2015
the low short-form health survey (SF-36) scores and health stressors across the 3 diseases. Besides some differences between diagnoses, the most important finding was the predominance of the evasive strategy and its association with low SF-36 score and high level of pain in patients with gout. Patients with rheumatic diseases cope in different ways when confronted with health and daily-life stressors. The strategy of coping differs across diagnoses; emotional/negative and evasive strategies are associated with poor health-related quality of life. The identification of the coping strategies could result in the design of psychosocial interventions to improve self-management. (Medicine 94(10):e600) Abbreviations: AS = ankylosing spondylitis, BASDAI = Bath Ankylosing Spondylitis Disease Activity Index, BASFI = Bath Ankylosing Spondylitis Functional Index, BASG = Bath Ankylosing Spondylitis Global Well-Being Index, CONACYT = National Council of Science and Technology of Me´xico, DAS28 = Disease Activity Scale, HAQ = Health Assessment Questionnaire, HRQoL = health-related quality of life, MCS-SF-36 = Mental Component Scale of Short Form-36, NRS = numerical rating scale, PCS-SF-36 = Physical Component Scale of Short Form-36, RA = rheumatoid arthritis, SF-36 = Short-Form Health Survey.
INTRODUCTION
T
he cognitive and behavioral adjustments that an individual uses to confront and manage health and daily-life stressors are referred to as ‘‘coping.’’1 –4 Strategies for coping arise from interpersonal components, the type of physical stressor, and sociocultural background.1,5 According to Folkman and Greer,4 and Sharpe and Curran,5 coping refers to the cognitive and behavioral adjustments made by the individual to confront and manage life stressors.4,5 Despite coping considered to be a personal trait, the individual may also develop specific strategies to confront stressors such as disease symptoms, functional limitations, psychological impact, and well-being low level.1 Although the spectrum of coping extends from the passive avoiding type to the active positive adjustment,3 the way of coping with chronic disease involves personal components, stressor’s nature, and sociocultural background.3,6 Patient’s beliefs and perception of illness influence the development of coping strategies. Despite coping being an individual trait, it might change over time, and in fact, most www.md-journal.com |
1
Medicine
Pela´ez-Ballestas et al
individuals develop specific strategies to confront specific stressors. The effect of coping strategies is usually classified as active or favorable, and passive or unfavorable.1,2 Of these, the ‘‘passive avoidant’’ and ‘‘active positive’’ strategies predominate in patients with stressful, chronic diseases; the former is also associated with diseases with the worst health outcomes.1,2 Rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout are painful and disabling chronic diseases that may profoundly affect quality of life of the patients and their relatives.6 The role of coping in patients with RA,7–9 as well as in patients with AS10 and other rheumatic diseases, has been studied.11–13 In general, the negative-emotional and evasive—passive/ avoidant strategies—are risk factors for poor adjustments to chronic diseases and poor outcome of variables such as quality of life, pain, adherence to treatment, and risky behaviors.3,6 Yet, it is still unknown if the way in which a particular person confronts health stressors is similar to that when coping with daily-life stressors. Similarly, we do not know whether coping strategies differ across diseases and whether such variations result from differences in disease-associated stressors or differences in personality traits.3,6 As cultural background plays an important role in coping, the study of different populations could shed light on the way people confront health and daily-life stressors. Based on that information, we hypothesize that depending on the disease, mental and physical health components, as well as personal and cultural factors, the way people confront health differs from that confronting daily-life stressors. In addition, we hypothesize that the evasive and emotional/ negative coping strategies are associated with poor healthrelated quality of life (HRQoL) whereas reappraisal and evasive strategies do not affect HRQoL. Therefore, in this study, on one hand, we aimed to compare the strategies for coping with health stressors as well as dailylife stressors in Mexican patients with RA, AS, and gout, and, on the other hand, the effect of variables on coping and health status in each particular disease.
METHODS This article is a cross-sectional study of the baseline data of a cohort of patients with RA,14 AS,15 and gout16 that determined their socioeconomic impact in Mexico.17 The cohort consisted of 693 outpatients, with disease onset after the age of 18 years, attending 11 institutional and private centers in 5 major cities in Mexico. The Institutional Review Board, with all the following centers: Hospital General de Me´xico ‘‘Eduardo Liceaga,’’ Hospital Universitario ‘‘Jose´ Eleuterio Gonzalez,’’ Hospital Gabriel Mancera Regional 1-IMSS, Hospital Civil de Guadalajara, Hospital General de zona 46-IMSS, and Hospital Central PEMEX, approved the study’s protocol and patients agreed to their participation in the study by signing an informed consent form. Sociodemographic variables included sex, age, occupation, paid-job status, disability allowances, monthly family income, health resource utilization, and disease cost impact (1 ¼ no impact, 2 ¼ moderate impact, 3 ¼ high impact). Clinical variables included those obtained by clinical history and physical examination, as well as pain level with a numerical rating scale (NRS; 0 no pain, 10 unbearable pain), and health status by the short-form (SF-36) questionnaire.18 In addition, patients with RA and gout filled the Health Assessment Questionnaire (HAQ),19 and patients with AS completed the Bath AS Disease Activity Index (BASDAI),20 the Bath AS Functional Index (BASFI), and
2
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Volume 94, Number 10, March 2015
the Bath AS Global Well-being (BASG) Indexes.21 The Cronbach a was estimated for all measurements made. The type of coping and its characteristics were assessed with a self-administered questionnaire developed and validated by Go´ngora3 in the Mexican population, following Folkman and Greer theory.4 Briefly, the questionnaire assessed the 2 domains of coping, health and daily life. Each of these domains included 18 questions related to 4 primary coping strategies: direct strategy, in which the individual attempted to adjust cognitively or behaviorally tackle the problem (eg, ‘‘When I have health problems, I take care of myself by following a course of treatment’’); emotional strategy, in which the individual deals with a problem in an emotional or negative way and expresses feelings that do not solve the problem directly (eg, ‘‘When I have health problems, I get upset’’); evasive strategy, in which the individual is willing to escape, avoid, or minimize the problem (eg, ‘‘When I have health problems, I try to sleep because I do not want to think about it’’); and reappraisal strategy, in which the individual tries to deal with the problem positively or somehow improves his/her perception of it (eg, ‘‘When I have health problems, I realize how important life is’’).3 Each of the 4 coping strategies is covered by 3 to 5 questions, providing a total of 18 for each of the domains. The response to each question is scored in a 7-point NRS, anchored with the levels ‘‘never’’ (1) and ‘‘always’’ (7). The scoring system includes the calculation of the mean of the answer given to each of the 4 coping strategy questions pertaining to health and daily-life domains. Based on the results of healthy individuals, mean values 4 indicate the dominance of 1 coping strategies in a particular patient.3 The sample size was obtained assuming a prevalence of 1% reported elsewhere, with a confidence level of 95% and the margin of error of 0.05, producing a total of 136 patients. Given that there were 5 referring institutions, 200 individuals were considered. Taking into account a 15% follow-up loss, the total of patients considered for the study was 224 in each group of disease, with a statistical power of 0.74. Sampling was nonprobabilistic. Questionnaire with missing data was excluded.
Statistical Analyses Sociodemographic, clinical measures and coping strategies were reported using descriptive statistics for each of the 3 disease groups and for the whole group of patients that included the Kruskal–Wallis test, ANOVA with Bonferroni’s correction, and the x2 test for continuous and categorical variables across diseases with a statistical significance level of 0.05 (2 sides). Results are expressed as odds ratio and 95% confidence intervals. Analysis included the whole patient population and each of the 3 diagnostic groups. The variables included in the models had a statistical significance of at least 0.2 and biological plausibility in the univariate analysis. The relation between coping strategies and health status (Physical Component Scale [PCS] and mental component Mental Component Scale [MCS] of short form [SF]-36) was analyzed in 2 linear regression models. In the first model, age, sex, economic impact, social support, and coping mechanisms were independent variables, whereas health status was dependent variable. In the second model, coping was the dependent variable whereas independent variables were age, sex, economic impact, social support, and health status. To explore the influence of coping on physical and mental health, 4 simple and 3 multiple regression models were performed with PCS and MCS-SF-36 components as dependent Copyright
#
2015 Wolters Kluwer Health, Inc. All rights reserved.
Medicine
Volume 94, Number 10, March 2015
Coping in RA, AS, and Gout
variables. The first model combined the 3 diagnostic groups. The next 3 models corresponded each to 1 diagnostic category. The 4 regression models shared first and second blocks of independent variables. The third block differed across regression models. In the first model, we included those clinical variables shared by all diagnostic categories, specifically disease duration and pain severity. The third block also included disease duration and pain severity as well as HAQ and Diseases Activity Scale (DAS28) for the RA model; BASFI, BASDAI, and BASGI for AS; and swollen joint count, tophi count, visual analog scale general health, and HAQ for gout. Interactions between coping strategies and disease toward each of the components of SF-36 were sought. Collinearity between variables was evaluated using 0.9 as threshold for acceptability. The models were evaluated using goodness-of-fit that was performed using the Hosmer–Lemeshow test. Interactions between coping mechanisms and disease toward each of the components of HRQoL were sought. Analyses were performed using STATA 9.0 statistical software (StataCorp LP, College Station, TX).
RESULTS In total, 693 participants were included in the study; their mean age (standard deviation) was 45.1 (14.8) years; 371 (53.5%) were men; 261 (37%) had RA, 226 (32.5%) had AS, and 206 (29.6%) had gout (Table 1). Sociodemographic variables differed across diagnoses. PCS-SF-36 and MCSSF-36 scores in patients with RA and AS were comparable and lower in patients with gout. Three hundred sixty-seven (53%) patients and 326 (47%) patients had 1 coping strategy to confront health and daily-life stressors, respectively (Figure 1). Men confronted health stressors with the evasive strategy (59.1% vs 30.9% in women, P 0.001), and daily-life stressors with the emotional/negative (50.6% vs 25% in women, P 0.001) and evasive strategies (37.2% vs 24.7% in women, P 0.001) (Table 2). Few patients confronted health stressors with direct strategies, or daily-life stressors with reappraisal. Evasive and reappraisal strategies prevailed when patients coped with health
stressors, whereas emotional/negative and evasive strategies predominated in patients coping with daily-life stressors (Figure 1) (Table 3). Overall, the proportion of patients coping with specific health and daily-life stressors differed across diagnoses. More patients with gout relied on coping strategies than patients with AS and RA. Reappraisal, emotional/negative, and evasive strategies were prominent in patients with gout and AS. The distribution of coping patterns across life and health dimensions in the 3 diseases was different. Reappraisal together with evasive and direct strategies was the most common coping pattern for health dimension (Table 3). The best-fitting models to explain the influence of sociodemographic and clinical variables on the use of evasive and direct strategies to cope with health stressors were fairly similar across diagnoses, including the type of disease used as dummy variable in the multivariate analysis (Table 4). The evasive coping strategy was most likely to be used by patients having RA with higher MCS-SF-36 scores and older age, and by patients with AS and gout with higher MCS-SF-36 and PCSSF-36 scores. In patients with gout, the use of direct coping strategies was associated with a high economic impact. When the 3 diagnostic categories were combined, PCS-SF-36 scores explained the evasive and direct strategies and MCS-SF-36 scores the evasive strategy. In contrast, being female and having a paid job eliminated the use of the evasive strategy. Patients using the evasive strategy for coping with health stressors were more likely to have low PCS-SF-36 and MC-SF36 scores, regardless of their disease (Table 5). In addition, high HAQ scores in patients with RA and gout, as well as high BASFI and BASDAI scores in AS, were associated with low PCS-SF-36 and MCS-SF-36 scores. High HAQ scores and the use of the evasive coping strategy were associated with low SF36 scores and high levels of pain with low PCS-SF-36 scores in patients with gout. The Cronbach a estimated for the internal consistency of each measure was 0. 85 (SF-36), 0.87 (BASDAI), 0.95 (BASFI), 0.96 (HAQ), and 0.85 (coping scale). With the exception of ‘‘direct’’ health coping style (0.27), the statistical power for all measurements was between 0.78 and 0.99.
TABLE 1. Sociodemographic and SF-36 Features of Patients Included in the Study Rheumatoid Arthritis Ankylosing Spondylitis (n ¼ 261) (n ¼ 226) Male, n (%) Age, y, mean (SD) Married, n (%) Education, y, mean (SD) Disease duration, y (IQR) Paid job, n (%) Monthly family income, US dollars, mean (IQR) Had some social support, n (%) High economic impact, n (%) Comorbidity, n (%) Health-related quality of life PCS-SF-36; mean (SD) MCS-SF-36; mean (SD)
28 46.2 176 9.0 2 95 376.1 66 207 65
(10.6) (13.7) (67.1) (4.0) (0–3) (36.4) (188.0–611.2) (25.1) (79) (24.8)
48.2 (22.5) 55.1 (21.1)
146 40.8 130 10.3 4 138 423.1 55 189 59
(64.6) (11.4) (57.5) (4.4) (1–8) (61.3) (235.0–799.2) (24.3) (83.6) (26.1)
48.2 (22.5) 55.1 (19.9)
Gout (n ¼ 206) 197 59.8 172 8.6 7 128 564.1 28 105 107
(95.6) (12.3) (83.5) (4.8) (1–14) (62.4) (263.1–1128.3) (13.6) (50.9) (51.9)
56.4 (24.6) 64.4 (19.3)
P
Abstract: This article aims to identify the strategies for coping with health and daily-life stressors of Mexican patients with chronic rheumatic disease. We analyzed the baseline data of a cohort of patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout. Their strategies for coping were identified with a validated questionnaire. Comparisons between health and daily-life stressors and between the 3 clinical conditions were made. With regression analyses, we determined the contribution of individual, socioeconomic, educational, and health-related quality-of-life variables to health status and coping strategy. We identified several predominant coping strategies in response to daily-life and health stressors in 261 patients with RA, 226 with AS, and 206 with gout. Evasive and reappraisal strategies were predominant when patients cope with health stressors; emotional/negative and evasive strategies predominated when coping with daily-life stressors. There was a significant association between the evasive pattern and Editor: Robert L. Barkin. Received: January 29, 2015; revised: February 5, 2015; accepted: February 6, 2015. From the Department of Rheumatology (IP-B, JV-M, JC-V, RB-V), Hospital General de Me´xico ‘‘Eduardo Liceaga,’’ Mexico City, Mexico; Maastricht University Medical Center (AB), The Netherlands; Postgraduate Department of Psychology (I-RL), Universidad Nacional Auto´noma de Me´xico, Mexico City; Department of Pediatrics (A-HG), Hospital Universitario ‘‘Jose´ Eleuterio Gonzalez’’, Monterrey, Nuevo Leon; Clinical Epidemiology Unit (MVG), Hospital Gabriel Mancera Regional 1, IMSS, Mexico City; Department of Rheumatology (AGB-M), Hospital Civil de Guadalajara, Guadalajara, Jalisco; Department of Rheumatology (JR-A, MAG-E), Hospital Universitario ‘‘Jose´ Eleuterio Gonzalez,’’ Monterrey, Nuevo Leon; Hospital General de zona 46 (FJA), IMSS and Unidad de Investigacio´n Croˆnico-Degenerativas, Guadalajara, Jalisco; and Department of Rheumatology (CS), Hospital Central, PEMEX, Mexico City, Mexico. Correspondence: Prof. Rube´n Burgos-Vargas, Department of Rheumatology, Hospital General de Me´xico and Faculty of Medicine, Universidad Nacional Auto´noma de Me´xico, Dr Balmis 148, colonia Doctores, Me´xico DF 06720, Me´xico (e-mail: [email protected]). IP-B and RB-V equally contributed to this study. This work was supported by the funds provided by the Salud 2002-C01-6434 programs of the National Council of Science and Technology of Me´xico (CONACYT). The authors have no conflicts of interest to disclose. Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000000600
Medicine
Volume 94, Number 10, March 2015
the low short-form health survey (SF-36) scores and health stressors across the 3 diseases. Besides some differences between diagnoses, the most important finding was the predominance of the evasive strategy and its association with low SF-36 score and high level of pain in patients with gout. Patients with rheumatic diseases cope in different ways when confronted with health and daily-life stressors. The strategy of coping differs across diagnoses; emotional/negative and evasive strategies are associated with poor health-related quality of life. The identification of the coping strategies could result in the design of psychosocial interventions to improve self-management. (Medicine 94(10):e600) Abbreviations: AS = ankylosing spondylitis, BASDAI = Bath Ankylosing Spondylitis Disease Activity Index, BASFI = Bath Ankylosing Spondylitis Functional Index, BASG = Bath Ankylosing Spondylitis Global Well-Being Index, CONACYT = National Council of Science and Technology of Me´xico, DAS28 = Disease Activity Scale, HAQ = Health Assessment Questionnaire, HRQoL = health-related quality of life, MCS-SF-36 = Mental Component Scale of Short Form-36, NRS = numerical rating scale, PCS-SF-36 = Physical Component Scale of Short Form-36, RA = rheumatoid arthritis, SF-36 = Short-Form Health Survey.
INTRODUCTION
T
he cognitive and behavioral adjustments that an individual uses to confront and manage health and daily-life stressors are referred to as ‘‘coping.’’1 –4 Strategies for coping arise from interpersonal components, the type of physical stressor, and sociocultural background.1,5 According to Folkman and Greer,4 and Sharpe and Curran,5 coping refers to the cognitive and behavioral adjustments made by the individual to confront and manage life stressors.4,5 Despite coping considered to be a personal trait, the individual may also develop specific strategies to confront stressors such as disease symptoms, functional limitations, psychological impact, and well-being low level.1 Although the spectrum of coping extends from the passive avoiding type to the active positive adjustment,3 the way of coping with chronic disease involves personal components, stressor’s nature, and sociocultural background.3,6 Patient’s beliefs and perception of illness influence the development of coping strategies. Despite coping being an individual trait, it might change over time, and in fact, most www.md-journal.com |
1
Medicine
Pela´ez-Ballestas et al
individuals develop specific strategies to confront specific stressors. The effect of coping strategies is usually classified as active or favorable, and passive or unfavorable.1,2 Of these, the ‘‘passive avoidant’’ and ‘‘active positive’’ strategies predominate in patients with stressful, chronic diseases; the former is also associated with diseases with the worst health outcomes.1,2 Rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout are painful and disabling chronic diseases that may profoundly affect quality of life of the patients and their relatives.6 The role of coping in patients with RA,7–9 as well as in patients with AS10 and other rheumatic diseases, has been studied.11–13 In general, the negative-emotional and evasive—passive/ avoidant strategies—are risk factors for poor adjustments to chronic diseases and poor outcome of variables such as quality of life, pain, adherence to treatment, and risky behaviors.3,6 Yet, it is still unknown if the way in which a particular person confronts health stressors is similar to that when coping with daily-life stressors. Similarly, we do not know whether coping strategies differ across diseases and whether such variations result from differences in disease-associated stressors or differences in personality traits.3,6 As cultural background plays an important role in coping, the study of different populations could shed light on the way people confront health and daily-life stressors. Based on that information, we hypothesize that depending on the disease, mental and physical health components, as well as personal and cultural factors, the way people confront health differs from that confronting daily-life stressors. In addition, we hypothesize that the evasive and emotional/ negative coping strategies are associated with poor healthrelated quality of life (HRQoL) whereas reappraisal and evasive strategies do not affect HRQoL. Therefore, in this study, on one hand, we aimed to compare the strategies for coping with health stressors as well as dailylife stressors in Mexican patients with RA, AS, and gout, and, on the other hand, the effect of variables on coping and health status in each particular disease.
METHODS This article is a cross-sectional study of the baseline data of a cohort of patients with RA,14 AS,15 and gout16 that determined their socioeconomic impact in Mexico.17 The cohort consisted of 693 outpatients, with disease onset after the age of 18 years, attending 11 institutional and private centers in 5 major cities in Mexico. The Institutional Review Board, with all the following centers: Hospital General de Me´xico ‘‘Eduardo Liceaga,’’ Hospital Universitario ‘‘Jose´ Eleuterio Gonzalez,’’ Hospital Gabriel Mancera Regional 1-IMSS, Hospital Civil de Guadalajara, Hospital General de zona 46-IMSS, and Hospital Central PEMEX, approved the study’s protocol and patients agreed to their participation in the study by signing an informed consent form. Sociodemographic variables included sex, age, occupation, paid-job status, disability allowances, monthly family income, health resource utilization, and disease cost impact (1 ¼ no impact, 2 ¼ moderate impact, 3 ¼ high impact). Clinical variables included those obtained by clinical history and physical examination, as well as pain level with a numerical rating scale (NRS; 0 no pain, 10 unbearable pain), and health status by the short-form (SF-36) questionnaire.18 In addition, patients with RA and gout filled the Health Assessment Questionnaire (HAQ),19 and patients with AS completed the Bath AS Disease Activity Index (BASDAI),20 the Bath AS Functional Index (BASFI), and
2
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Volume 94, Number 10, March 2015
the Bath AS Global Well-being (BASG) Indexes.21 The Cronbach a was estimated for all measurements made. The type of coping and its characteristics were assessed with a self-administered questionnaire developed and validated by Go´ngora3 in the Mexican population, following Folkman and Greer theory.4 Briefly, the questionnaire assessed the 2 domains of coping, health and daily life. Each of these domains included 18 questions related to 4 primary coping strategies: direct strategy, in which the individual attempted to adjust cognitively or behaviorally tackle the problem (eg, ‘‘When I have health problems, I take care of myself by following a course of treatment’’); emotional strategy, in which the individual deals with a problem in an emotional or negative way and expresses feelings that do not solve the problem directly (eg, ‘‘When I have health problems, I get upset’’); evasive strategy, in which the individual is willing to escape, avoid, or minimize the problem (eg, ‘‘When I have health problems, I try to sleep because I do not want to think about it’’); and reappraisal strategy, in which the individual tries to deal with the problem positively or somehow improves his/her perception of it (eg, ‘‘When I have health problems, I realize how important life is’’).3 Each of the 4 coping strategies is covered by 3 to 5 questions, providing a total of 18 for each of the domains. The response to each question is scored in a 7-point NRS, anchored with the levels ‘‘never’’ (1) and ‘‘always’’ (7). The scoring system includes the calculation of the mean of the answer given to each of the 4 coping strategy questions pertaining to health and daily-life domains. Based on the results of healthy individuals, mean values 4 indicate the dominance of 1 coping strategies in a particular patient.3 The sample size was obtained assuming a prevalence of 1% reported elsewhere, with a confidence level of 95% and the margin of error of 0.05, producing a total of 136 patients. Given that there were 5 referring institutions, 200 individuals were considered. Taking into account a 15% follow-up loss, the total of patients considered for the study was 224 in each group of disease, with a statistical power of 0.74. Sampling was nonprobabilistic. Questionnaire with missing data was excluded.
Statistical Analyses Sociodemographic, clinical measures and coping strategies were reported using descriptive statistics for each of the 3 disease groups and for the whole group of patients that included the Kruskal–Wallis test, ANOVA with Bonferroni’s correction, and the x2 test for continuous and categorical variables across diseases with a statistical significance level of 0.05 (2 sides). Results are expressed as odds ratio and 95% confidence intervals. Analysis included the whole patient population and each of the 3 diagnostic groups. The variables included in the models had a statistical significance of at least 0.2 and biological plausibility in the univariate analysis. The relation between coping strategies and health status (Physical Component Scale [PCS] and mental component Mental Component Scale [MCS] of short form [SF]-36) was analyzed in 2 linear regression models. In the first model, age, sex, economic impact, social support, and coping mechanisms were independent variables, whereas health status was dependent variable. In the second model, coping was the dependent variable whereas independent variables were age, sex, economic impact, social support, and health status. To explore the influence of coping on physical and mental health, 4 simple and 3 multiple regression models were performed with PCS and MCS-SF-36 components as dependent Copyright
#
2015 Wolters Kluwer Health, Inc. All rights reserved.
Medicine
Volume 94, Number 10, March 2015
Coping in RA, AS, and Gout
variables. The first model combined the 3 diagnostic groups. The next 3 models corresponded each to 1 diagnostic category. The 4 regression models shared first and second blocks of independent variables. The third block differed across regression models. In the first model, we included those clinical variables shared by all diagnostic categories, specifically disease duration and pain severity. The third block also included disease duration and pain severity as well as HAQ and Diseases Activity Scale (DAS28) for the RA model; BASFI, BASDAI, and BASGI for AS; and swollen joint count, tophi count, visual analog scale general health, and HAQ for gout. Interactions between coping strategies and disease toward each of the components of SF-36 were sought. Collinearity between variables was evaluated using 0.9 as threshold for acceptability. The models were evaluated using goodness-of-fit that was performed using the Hosmer–Lemeshow test. Interactions between coping mechanisms and disease toward each of the components of HRQoL were sought. Analyses were performed using STATA 9.0 statistical software (StataCorp LP, College Station, TX).
RESULTS In total, 693 participants were included in the study; their mean age (standard deviation) was 45.1 (14.8) years; 371 (53.5%) were men; 261 (37%) had RA, 226 (32.5%) had AS, and 206 (29.6%) had gout (Table 1). Sociodemographic variables differed across diagnoses. PCS-SF-36 and MCSSF-36 scores in patients with RA and AS were comparable and lower in patients with gout. Three hundred sixty-seven (53%) patients and 326 (47%) patients had 1 coping strategy to confront health and daily-life stressors, respectively (Figure 1). Men confronted health stressors with the evasive strategy (59.1% vs 30.9% in women, P 0.001), and daily-life stressors with the emotional/negative (50.6% vs 25% in women, P 0.001) and evasive strategies (37.2% vs 24.7% in women, P 0.001) (Table 2). Few patients confronted health stressors with direct strategies, or daily-life stressors with reappraisal. Evasive and reappraisal strategies prevailed when patients coped with health
stressors, whereas emotional/negative and evasive strategies predominated in patients coping with daily-life stressors (Figure 1) (Table 3). Overall, the proportion of patients coping with specific health and daily-life stressors differed across diagnoses. More patients with gout relied on coping strategies than patients with AS and RA. Reappraisal, emotional/negative, and evasive strategies were prominent in patients with gout and AS. The distribution of coping patterns across life and health dimensions in the 3 diseases was different. Reappraisal together with evasive and direct strategies was the most common coping pattern for health dimension (Table 3). The best-fitting models to explain the influence of sociodemographic and clinical variables on the use of evasive and direct strategies to cope with health stressors were fairly similar across diagnoses, including the type of disease used as dummy variable in the multivariate analysis (Table 4). The evasive coping strategy was most likely to be used by patients having RA with higher MCS-SF-36 scores and older age, and by patients with AS and gout with higher MCS-SF-36 and PCSSF-36 scores. In patients with gout, the use of direct coping strategies was associated with a high economic impact. When the 3 diagnostic categories were combined, PCS-SF-36 scores explained the evasive and direct strategies and MCS-SF-36 scores the evasive strategy. In contrast, being female and having a paid job eliminated the use of the evasive strategy. Patients using the evasive strategy for coping with health stressors were more likely to have low PCS-SF-36 and MC-SF36 scores, regardless of their disease (Table 5). In addition, high HAQ scores in patients with RA and gout, as well as high BASFI and BASDAI scores in AS, were associated with low PCS-SF-36 and MCS-SF-36 scores. High HAQ scores and the use of the evasive coping strategy were associated with low SF36 scores and high levels of pain with low PCS-SF-36 scores in patients with gout. The Cronbach a estimated for the internal consistency of each measure was 0. 85 (SF-36), 0.87 (BASDAI), 0.95 (BASFI), 0.96 (HAQ), and 0.85 (coping scale). With the exception of ‘‘direct’’ health coping style (0.27), the statistical power for all measurements was between 0.78 and 0.99.
TABLE 1. Sociodemographic and SF-36 Features of Patients Included in the Study Rheumatoid Arthritis Ankylosing Spondylitis (n ¼ 261) (n ¼ 226) Male, n (%) Age, y, mean (SD) Married, n (%) Education, y, mean (SD) Disease duration, y (IQR) Paid job, n (%) Monthly family income, US dollars, mean (IQR) Had some social support, n (%) High economic impact, n (%) Comorbidity, n (%) Health-related quality of life PCS-SF-36; mean (SD) MCS-SF-36; mean (SD)
28 46.2 176 9.0 2 95 376.1 66 207 65
(10.6) (13.7) (67.1) (4.0) (0–3) (36.4) (188.0–611.2) (25.1) (79) (24.8)
48.2 (22.5) 55.1 (21.1)
146 40.8 130 10.3 4 138 423.1 55 189 59
(64.6) (11.4) (57.5) (4.4) (1–8) (61.3) (235.0–799.2) (24.3) (83.6) (26.1)
48.2 (22.5) 55.1 (19.9)
Gout (n ¼ 206) 197 59.8 172 8.6 7 128 564.1 28 105 107
(95.6) (12.3) (83.5) (4.8) (1–14) (62.4) (263.1–1128.3) (13.6) (50.9) (51.9)
56.4 (24.6) 64.4 (19.3)
P
